DisCORDant Symptoms Simplified - OHSU

Discordant Symptoms Simplified

Kristy T. Duggan, MD

November 2, 2017

ACP – Oregon Chapter Meeting

Salem, OR

Once upon a time…

“I can’t breathe!”

Over the last week…

Can’t get air in or out

Taxing to talk

Happens randomly (rest/exertion)

Worse laying down

Worse in her condo

Worse working with fiber art

Bloating, belching

Difficulty breathing

Has had before, but never this bad

Non-productive cough

Constitutional: Positive for fatigue, weight gain. Respiratory: Positive for cough and shortness of breath. Cardiovascular: Positive for palpitations, orthopnea, paroxysmal nocturnal dyspnea. Gastrointestinal: Positive for epigastric pain, diarrhea, flatus. Musculoskeletal: Positive for back pain, joint pain and myalgias.Skin: Positive for facial rash. Neurological: Positive for lightheadedness and headaches. Psychiatric: Positive for anxiety and insomnia.

Her ROS…

YIKES!

Historical Context

Past Medical History:

- Obstructive sleep apnea (uses mouth device)

- Paroxysmal SVT s/p remote ablation

- Prediabetes

- Hyperlipidemia

- Thyroid nodules

- PTSD (trauma-related deaths of parents & son)

- History of smoking (18 pack years)

Family History:

- Sister - lung cancer

Social History:

- Frequent & recent travel

Vital Signs

- Afebrile- BP 128/78 mm Hg- HR 77 bpm- RR 14 - O2 98% on RA- BMI 29

General: alert, cooperative, somewhat uncomfortable appearingHEENT: normal conjunctivae and anicteric sclerae, oropharynx clear without lesion or exudates and appearance of ears/nose normal without lesionsNeck: JVP not distended, no goiter or thyroid nodules palpatedHeart: regular rate and rhythm, S1, S2 normal, no S3 or S4, no murmur, click, or rubLung: chest is clear without rales or wheezing Abdomen: abdomen is soft, no masses or organomegaly and bowel sounds normal. Mildly tender to deep palpation in epigastric regionExtremities: extremities normal without deformity, no clubbing or cyanosis, no edemaSkin: skin color, texture, turgor normal. No rashes or lesionsPsych: normal affect, not apparently anxious or depressed, judgment and insight appropriate in context of visit and apparently normal recent and remote memory

NORMAL

Physical Exam

So… now what?

Approach to Dyspnea

Neurological/Psychiatric• Myasthenia Gravis• Toxidromes• Anxiety, Panic attacks

Upper Airway• Laryngitis/epiglottitis• Angioedema• Thyroid disease• Vocal cord dysfunction

Pulmonary• Asthma, COPD• Pneumonia, Pleural Effusion• Interstitial Lung Disease• Pulmonary Embolism• Malignancy

Cardiac• Coronary artery disease• Congestive heart failure• Arrhythmia

Abdominal• GERD• Cirrhosis with ascites

Heme• Anemia• CO poisoning• Methemoglobinemia

CBCBMP

TnD-dimer TSH

BNP VBG

NORMAL

Predicted

Actual

One week later…

NORMAL

“By the way, Doc, I’m leaving for Uganda

this weekend. I’ll be gone for a month.”

Approach to Dyspnea




Cardiac• Coronary artery disease• Congestive heart failure• Arrhythmia



NORMAL

MILD ASTHMA


Approach to Dyspnea


Cardiac• Acute coronary syndrome• Congestive heart failure• Arrhythmia







Cardiac• Acute coronary syndrome• Congestive heart failure• Arrhythmia

VOCAL CORD DYSFUNCTION

Extensive lab testingChest X-ray x2EKGPeak flow meterThyroid ultrasoundPulmonary function tests x2Stress echocardiogram

$5698!

$7038!

$5698

Episodic laryngeal dyskinesia

Vocal cord dysfunction

Paradoxical vocal cord movement

Paradoxical vocal fold motion

Munchhausen's stridor

Episodic paroxysmal laryngospasm

Inducible laryngeal obstruction

Irritable larynx syndrome

Functional upper airway obstruction

Functional laryngeal stridor

Psychogenic stridor

What’s in a name?

Bardin PG, Low K, Ruane L, et al. Lancet – Respiratory. 2017; 5:546-548.

Healthy people

Dysfunctional breathing

Anxiety, hyperventilation

Unstable asthma

People with asthma

Shortness of breath

Middle airway obstruction

PVCM/VCD

Activation laryngeal reflexes

Laryngeal hyperresponsiveness• Sinus disease• Reflux/inhaled

irritantsOther factors• Reduced FEV1• High BMI• Anxiety/

depression• Female gender

Bardin PG, Low K, Ruane L, et al. Lancet – Respiratory. 2017; 5:546-548.

Healthy people

Dysfunctional breathing

Anxiety, hyperventilation

Unstable asthma

People with asthma

Shortness of breath

Middle airway obstruction

PVCM/VCD

Activation laryngeal reflexes

Laryngeal hyperresponsiveness• Sinus disease• Reflux/inhaled

irritantsOther factors• Reduced FEV1• High BMI• Anxiety/

depression• Female gender

VCDKenn K and Balkissoon R. Eur Respir J. 2011; 37:194-200.

Illness Script

A young woman with a history of anxiety presents with acute

episodic dyspnea of short duration amongst discordant symptoms

including dysphonia and bloating, found to have

normal vital signs and exam.

Dyspnea out of proportion to exam?

Diagnostic Testing

Flexible Fiberoptic Laryngoscopy

Management

… aND she lived happily

ever after

Final Thoughts

• Heightened awareness and diagnostic accuracy

• Fewer invasive diagnostic & therapeutic interventions

• Cost conscious care

DisCORDantSymptoms Simplified

Questions?

References

• Bardin PG, Low K, Ruane L, et al. Controversies and conundrums in vocal cord dysfunction. Lancet – Respiratory. 2017; 5:546-548.

• Christopher KL, Wood RP, Eckert RC, et al. Vocal cord dysfunction presenting as asthma. N Engl J Med 1983; 308: 1566–1570.

• Kenn K and Balkissoon R. Vocal cord dysfunction: what do we know? Eur Respir J. 2011; 37:194-200.

• Newman KB, Mason UG, Schmaling KB. Clinical features of vocal cord dysfunction. Am J Respir Crit Care Med 1995; 152: 1382–1386.

• Patterson R, Schatz M, Horton M. Munchhausen's stridor: nonorganic laryngeal obstruction. Clin Allergy. 1974; 4:307-310.

• Vocal cord dysfunction or inducible laryngeal obstruction: whatever it is, it exists. Lancet – Respiratory. 2017; 5:8 -548.

1. General visualization

2. “EEE”

3. Quiet breathing

4. Forced vital capacity maneuver

Kenn K and Balkissoon R. Eur Respir J. 2011; 37:194-200.

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DisCORDant Symptoms Simplified - OHSU